Sutures for Tendon Repair
Tendon repair is among the most mechanically demanding applications for surgical sutures. The repaired tendon must withstand the forces of early active mobilization, which modern rehabilitation protocols increasingly favor over prolonged immobilization. Suture failure — whether through knot slippage, suture pullout, or material breakage — leads to gap formation and functional loss. Suture selection must therefore prioritize tensile strength, knot security, and minimal elongation under cyclic loading.
Key Suture Selection Considerations
Core sutures must be non-absorbable or very slowly absorbable with high tensile strength — tendons heal slowly (6–12 weeks) and require sustained mechanical support.
Braided non-absorbable sutures offer superior knot security, which is critical because knot failure is the most common mode of tendon repair failure.
Monofilament sutures glide better through tendon tissue, reducing friction and tissue disruption during the repair — important for preserving tendon vascularity.
Multi-strand core suture techniques (4-strand or 6-strand) significantly increase repair strength compared to 2-strand techniques.
Epitendinous (peripheral) sutures should be fine monofilament to create a smooth gliding surface and prevent triggering within tendon sheaths.
Suture caliber for core repairs is typically 3-0 or 4-0 for hand flexor tendons and 2 or 0 for large tendons like the Achilles.
Recommended Desmo Care Sutures
DesmoMid
Polypropylene monofilament with permanent tensile strength and lowest tissue reactivity — excellent for core tendon repair where smooth gliding and lasting support are essential.
DesmoSter
Braided polyester with permanent strength and exceptional knot security — ideal for Achilles tendon, rotator cuff, and large tendon core repairs requiring high mechanical load resistance.
DesmoPol
PDO monofilament with 180+ days of support — suited for epitendinous circumferential sutures where eventual absorption reduces adhesion formation on the gliding surface.
DesmoCapro
PLLA-PCL monofilament with 180 days of tensile support — an alternative for core repairs when a slowly absorbable suture is preferred over a permanent material.
Clinical Notes & Best Practices
Modern tendon repair emphasizes multi-strand core suture configurations with an epitendinous peripheral suture. For zone II flexor tendon repair, a 4-strand or 6-strand core suture using 3-0 or 4-0 non-absorbable suture (modified Kessler, cruciate, or Adelaide technique) is placed through the tendon substance, with each strand crossing the repair site. Knots should be buried within the repair to minimize gliding friction. The epitendinous suture — a running horizontal mattress or cross-stitch pattern using 5-0 or 6-0 monofilament — adds approximately 50% to the total repair strength and creates a smooth outer surface. For Achilles tendon repair, Krackow locking sutures with 0 or 2 braided non-absorbable suture provide strong fixation. Grasping sutures should be placed at least 1 cm from the tendon edge to prevent pull-through. Early active mobilization protocols require a minimum 4-strand core repair with an epitendinous suture to generate the approximately 35 N needed for active finger flexion.
Frequently Asked Questions
What sutures are best for flexor tendon repair?
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Flexor tendon repair requires 3-0 or 4-0 non-absorbable or slowly absorbable core sutures (DesmoMid, DesmoSter, or DesmoCapro) in a multi-strand configuration, combined with 5-0 or 6-0 monofilament epitendinous sutures (DesmoPol) for a smooth gliding surface.
Why are non-absorbable sutures preferred for tendon repair?
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Tendons heal very slowly — taking 6–12 weeks to regain meaningful strength. Non-absorbable sutures like polypropylene (DesmoMid) and braided polyester (DesmoSter) maintain their tensile strength indefinitely, providing continuous mechanical support throughout this prolonged healing period.
How many suture strands are needed for a strong tendon repair?
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Current evidence supports a minimum of 4-strand core suture repairs for tendons that will undergo early active mobilization. Six-strand repairs provide even greater strength. Each additional strand crossing the repair site increases the ultimate failure load by approximately 10–15 N.
What suture should I use for Achilles tendon repair?
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Achilles tendon repair requires heavy (size 0 or 2) non-absorbable braided sutures (DesmoSter) placed in a locking configuration (Krackow technique). The braided construction provides superior knot security under the high mechanical loads this tendon experiences.
How does the epitendinous suture improve tendon repair?
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The epitendinous (peripheral) suture adds approximately 50% to total repair strength, smooths the tendon surface for improved gliding, and reduces gap formation at the repair site. Use a fine monofilament (5-0 or 6-0 DesmoPol) in a running pattern to minimize surface irregularity.
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